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NEUROLOGIC EVALUATION:Pathologic Reflexes Tests:TOP OF PAGE Platysma Sign This is a pathologic reflex of the head indicating ipsilateral corticorspinal tract disease as seen in hemiplegia. The sign is present when the examiner applies counter-pressure to the patient’s flexing of the chin toward the chest. The Platysma muscle contracts on the sound side only, drawing the outer part of the lower lip downward and backward. The Snout Reflex This is a pathologic reflex of the head most frequently seen in bilateral corticopontine lesions and indicates an upper motor neuron lesion. This reflex is considered positive when sharp tapping of the nose or of the middle of the upper lip causes an excessive face grimace or an exaggerated reflexion contraction of the lips. The Zygomatic Reflex. On this test the examiner taps the Zygoma lightly with a reflex hammer. If this results in lateral motion of the lower jaw on the percussed side, then the reflex is positive, indicating damage to the cortical innervation of the motor portion of the Trigeminal Nerve. The Finger Thumb Reflex This test is done by the examiner firmly flexing the third to fifth finger of each of the patient’s hands at the proximal joints. This action produces opposition and adduction of the thumb and flexion at the metacarpophalangeal joint. This reflex is absent in patients with corticospinal lesions. If the reflex is absent only on one side it indicates a possible Pyramidal Tract lesion. Kleist’s Hooking Sign This is an upper extremity pathologic reflex performed by the examiner gently elevating the patient’s fingers with his or her own fingers. If the patient’s involved hand reactively flexes and hooks into the examiner’s fingers instead of passively going into extension, then this sign is considered present, indicating Frontal and Thalamic lesions. Klippel-Weil Sign This is an upper extremity pathologic reflex sign which is considered present when the flexed fingers of the patient’s affected limb are quickly pried open or extended by the examiner and it results in flexion and adduction of the patient’s thumb. The sign’s presence indicates Pyramidal Tract disease. Babinski Reflex In this test, which is considered the most constant of the pathologic reflexes, the plantar surface of the foot is directly and firmly stroked from the heel to the metatarsophalangeal joints, testing both inner & outer borders of the sole. If this results in a slow, tonic digital extension of the great toe with fanning of other toes (which usually disappears after the stimulus is removed), as opposed to a voluntary response (which is faster and usually accompanied by a rapid withdrawal of the leg), it indicates Corticospinal (Pyramidal) Tract disease. Gordon’s Reflex This is a lower extremity pathologic reflex where dorsiflexion of the great toe or all the toes results when the calf muscles are firmly compressed by the examiner. A positive reflex indicates a Pyramidal Tract lesion. Oppenheim Sign This is a lower extremity pathologic reflex where the examiner applies heavy pressure with the index fingers and thumb or with the knuckles of the index and middle fingers along the anterior tibial surface on either side of the tibial crest, stroking from the tibial tubercle down to the ankle. If at the end of this stimulation there is a slow, tonic digital extension of the great toe with fanning of the other toes, the sign is considered present, indicating Corticospinal (Pyramidal) Tract disease. Strumpell’s Tibialis Anterior Sign This test is performed with the patient supine. The examiner places one hand under the patient’s knee and the other hand over the middle anterior tibial third. First, the examiner strongly flexes the hip on the pelvis. Then, using the other hand, the examiner firmly flexes the knee. The sign is considered present when either of these actions causes dorsiflexion and adduction of the foot, indicating an upper motor neuron lesion (Spastic paralysis) of the lower limb. Auditory Nerve Disorder Tests:TOP OF PAGEBing’s Test In this test, a 256 Hz tuning fork is placed on the top or crown of the patient’s head, while having the patient cover one ear. Normally, the blocked ear hears the sound the best by way of bone conduction. If no sound is heard in the covered ear, then the test is considered positive, indicating nerve deafness. Gruber Test . The examiner holds a vibrating tuning fork close to the patient’s ear until the patient indicates he can no longer hear it. At that point, using his or her index finger, the examiner blocks off the patient’s external auditory canal and places the still vibrating tuning fork against the finger. If the sound does not become audible again, then this test is considered positive, indicating a lack of sensitivity of the ear to sounds. The Rinne Test In this test, the stem of a vibrating 256 or 512 cycle tuning fork is placed on the mastoid process of the Temporal Bone. When the patient reports no longer hearing the sound, the opposite end of the tuning fork is immediately held in front of the patient’s ear about half inch from the external auditory meatus until the patient again reports no longer hearing the sound. If the sound is heard longer externally through air conduction, the test is considered Rinne Positive, which is normal. If the sound is heard for equal lengths of time at both positions, the test is considered Rinne Equal. If the sound is heard longer on the mastoid process (bone conduction), it is considered Rinne Negative. Rinne Equal or Rinne Negative indicates a physical obstruction of some sort in the airway or possibly middle ear disease. In the case of severe nerve deafness, no sound is heard at all. The Weber (Lateralization) Test With the patient seated, the examiner places the stem of a vibrating 256 cycle tuning fork on the patient’s vertex or on the midline of the forehead just above the glabella. If the sound is heard equally on both sides, the test is considered Weber Negative, which is a normal response. If the sound is heard better on one side (lateralization), it is considered “Weber Left” or “Weber Right”, relative to the side on which it is best heard. Clonus Tests:TOP OF PAGE Suprapatellar Reflex This reflex is tested with the patient supine with both limbs straight and parallel. Using his or her index finger, the examiner exerts downward pressure on the patellar toward the feet. Using the index finger as a pleximeter, the superior portion of the patella is stroked posteriorward and toward the feet with a reflex hammer. Normally there is a single rebound response of the patella for each percussion. More than one kickback per stroke indicates suprapatellar clonus, which is one of the criteria for an upper motor neuron lesion. Trepidation Sign This reflex is tested with the patient supine with both limbs straight and parallel. Using his or her index finger, the examiner exerts downward pressure on the patellar toward the feet. Using the index finger as a pleximeter, the superior portion of the patella is stroked posteriorward and toward the feet with a reflex hammer. Normally there is a single rebound response of the patella for each percussion. When the patella goes into a rapid up and down movement, it is called The Trepidation Sign, which is one of the indicators of an upper motor neuron lesion. Posterior Column Disorders:TOP OF PAGE The Finger to Finger Test In this test the patient with outstretched arms attempts to bring the tips of the index fingers together. The test is done with the eyes open and closed. If the patient can hit the mark with the eyes open but not closed, the test is considered positive, indicating Posterior Column Disease. If the patient cannot hit the mark in a coordinated way with eyes open or closed, then Cerebellar Disease is indicated. The Finger to Nose Test In this test the patient with outstretched arms attempts to alternately bring the tip of each index finger to the tip of the nose. The test is done with the eyes open and closed. If the patient can hit the mark with the eyes open but not closed, the test is considered positive, indicating Posterior Column Disease. If the patient cannot hit the mark in a coordinated way with eyes open or closed, then Cerebellar Disease is indicated. The Heel-Knee Test This test is done with the patient supine. The patient places the heel of one foot on top of the opposite knee and slowly slides the heel down the shin to the ankle. The test is done bilaterally first with the eyes open, then with the eyes closed. If the patient is unable to smoothly perform the above, then the test is considered positive, revealing evidence of proprioceptive system imbalance. More specifically, if the patient can perform the above better with the eyes open than closed, then Posterior Column Disease is indicated. If the patient cannot perform the test well with eyes open or closed, then a Cerebellar lesion is indicated. The Heel-Toe Test In this test the patient walks a straight line heel to toe about ten steps forward, turns around, then returns ten steps back. Providing there is normal lower limb strength, this action should be done without faltering or loss of balance. If the patient is unable to perform the test normally, it is considered positive, indicating evidence of proprioceptive system imbalance. Lhermitte’s Sign This sign is present when bending the neck into flexion causes an electric shock like sensation to radiate down the neck and spine, which is indicative of Posterior Column disease of the spinal cord. Romberg’s Sign In this test, the patient stands upright with feet together and hands at the side. A slight amount of swaying is normal, but if the patient is unable to maintain balance without moving the feet, with the eyes open or closed, this sign is considered present, indicating spinal cord Posterior Column disease, notably Multiple Sclerosis and Tabes. Brachial Plexus Disorders:TOP OF PAGE Bikele’s Sign With the patient outstretching the arm upward and backward with the elbow fully flexed, extending the elbow causes resistance and increased radicular pain from the cervicothoracic region. Because of the stretch this action puts on the brachial plexus nerve roots or their covering, it results in brachial plexus neuritis or meningitis symptomatology when this sign is present. Brachial Plexus Tension Test The patient elevates the shoulders through abduction and then extends the elbows to the onset of pain and hods for several seconds. This is followed by the external rotation of the shoulders which is held for several seconds. The examiner supports the shoulders and forearm in this position while the patient flexes the elbows. Reproduction of symptoms is a positive finding and may suggest brachial plexus or cervical root involvement Cranial Nerve Testing:TOP OF PAGE There are 12 pair of cranial nerves which are routinely examined on patients who have complaints which may suggest pathology. Below is a list of the 12 nerve and their function: I Olfactory N. Smell II Optic N. Vision III Oculomotor N. Light accommodation, eye movement IV Trochlear N Eye Movement V Trigeminal N. Facial sensation VI Abducens N. Eye Movement VII Facial N. Facial Muscle, Taste VIII Auditory N Auditory function and balance IX Glossopharangeal N. Taste, gag X Vagus N. Voice and swallow XI Spinal Accessory N. Shoulder shrug XII Hypoglossal N. Tongue Movement Peripheral Nerve Tests:TOP OF PAGE The Biceps Reflex The patient is seated with the forearms resting on the thighs. The examiner places the biceps tendon under slight tension by placing his or her thumb over the center of the tendon. Using a percussion hammer, the examiner strikes his thumbnail, observing and feeling the flexion of the elbow and contraction of the Biceps Muscle, which normally results, otherwise the test is positive. A positive test may indicate an upper and lower motor neuron lesion as well as ascertaining the integrity of afferent and efferent fibers of the Musculocutaneous Nerve. The Brachioradialis This reflex is tested with the patient seated with the forearms resting on the thighs with the thumbs facing up. While palpating the belly of the Brachioradialis, the examiner strokes its tendon with a reflex hammer at its point of maximum response. In a true brachioradialis stretch reflex, only the forearm will flex. This reflex is used to determine the afferent and efferent integrity of the Radial Nerve in relation to an upper or lower motor neuron lesion. The Infraspinatus Reflex This reflex is tested with the patient seated. The examiner strokes the area over the scapula with a reflex hammer at a point that’s on a line that bisects the angle formed by the spine of the bone and its inner border. A normal reflex would be external rotation of the arm along with extension of the elbow. A positive test indicates a lack of integrity of the C5/C6 nerve roots and the Suprascapular Nerve. The Pectoral Reflex The examiner puts his or her index finger over the anterior fold of the axilla, hooking the tendon of the Pectoralis Muscle. The patient’s arm is positioned halfway between adduction and abduction. The examiner then strokes the tendon with a reflex hammer. A normal response is little, if any, contraction of the Pectoralis Muscle. If there is hyperreflexia when compared to the opposite side, it is indicative of a Corticospinal Tract lesion above the level of the fifth cervical segment. The Radial Reflex In this test, the seated patient rests the forearms on the thighs with the thumbs facing upward. The examiner taps the forearm over the radius proximal to its styloid process, working upward until the point of maximum response is located. A normal response would be slight supination, flexion and radial deviation of the hand. Hypo or Hyperreflexia reveals lack of C5/C6 segmental integrity, indicating an upper or lower motor neuron lesion. The Inverted Radial Reflex This reflex is tested with the patient seated with the forearms resting on the thighs with the thumbs facing up. While palpating the belly of the Brachioradialis, the examiner strokes its tendon with a reflex hammer at its point of maximum response. When this action causes flexion of the hand and fingers without forearm flexion or response, then the test is positive, which is considered an important arm reflex indicative of a lesion of the 5th Cervical segment of the spinal cord. The Ulnar Reflex This reflex is tested with the patient seated with the forearms resting on the thighs with the elbows at right angles and palms facing downward. While palpating the ulnar musculature with one hand, the examiner strokes the styloid process of the ulna right next to the apex with a glancing blow from medial to lateral. The normal response to this reflex would be minimal pronation and ulnar deviation of the hand. A positive reflex indicates a lack of integrity of the afferent and efferent fibers of the Ulnar Nerve through their center C8 and T1. Tinel Sign This test is performed by gentle tapping with the finger or reflex hammer over the site or along the course of the involved nerve. If pain and/or a tingling sensation results in the distal distribution of the injured nerve, which persists for several seconds, the sign is considered present, indicating Carpal Tunnel Syndrome. Phalen’s Sign Inthis test, the wrist is held in complete flexion for 30 to 60 seconds. This sign is present when discomfort, numbness & paresthesia is reproduced or exaggerated in the hand & digits, indicating median nerve compression such as in Carpal Tunnel Syndrome. Wartenberg’s (Oriental Prayer) In this test the patient adducts and extends the fingers while extending the thumbs. The examiner then has the patient raise both hands so they are side by side facing the floor, with the thumbs and index fingers touching tip to tip. The thumbs will not coincide when the index fingers touch, if there is paralysis of the Abductor Pollicis Brevis, indicative of Median Nerve palsy. Lumbosacral Nerve Tests:TOP OF PAGE The Heel-Walk Test The patient walks on the heels several steps forward, then back the same way. If the patient has low back complaints and is unable to perform this action because of either pain or weakness, then a lesion of the fibers of the L5 Nerve Root should be suspected. O’Connell’s Test Specifically, a positive test would be evidence of neuritis proximal to the distal extent of the radiculopathy. The Quadriceps Reflex In this test, the patient should be completely relaxed, with both lower limbs parallel and fully extended. The examiner elevates the limbs slightly by placing his or her forearm under the patient’s knees. The examiner then palpates the patellar tendons and then briskly strokes each side equally with a reflex hammer observing and comparing the response of the Quadriceps’ contractions and knee extensions. Hyporeflexia or hyperreflexia may indicate a lower or upper motor neuron lesion of the L2, L3 or L4 nerve roots or of the Femoral Nerve. The Toe Walk Test In this test the patient walks on the toes about seven steps forward, turns still on the toes, then walks back the seven steps. The patient’s inability to do this easily could indicate a loss of integrity of fibers from the S1-2 nerve roots.

ORTHOPEDIC EVALUATION:

Cervical Lesion Tests:TOP OF PAGE Bakody Sign This test is normally done with patients who have cervical radicular pain. The patient actively places the palm of the affected extremity flat on the top of the head while raising the elbow level with the head. When this action reduces or eliminates the radiating pain, the sign is considered present. A positive sign is indicative of nerve root irritation because of cervical foraminal compression. The Cervical Distraction Test While seated, the patient actively rotates the head and neck until radicular pain is produced. The examiner then rotates the head to the same extent but with strong upward traction added to the motion. If this action performed by the examiner gives relief or significantly reduces the patient’s cervical and/or radicular pain, this test is considered positive, indicating nerve root compression. If the patient can’t actively rotate the head or neck because of pain, the examiner can still do this test by adding traction with or without rotation. The Jackson Compression Test In this test, the patient, sitting upright, attempts to laterally flex the neck and head toward the affected shoulder. Then the examiner exerts downward pressure with clasped hands on top of the patient’s head. The test is positive if this action exacerbates the patient’s cervical and/or radicular pain indicating nerve root compression.The Maximum Cervical Compression Test In this test, the patient, sitting upright, attempts to laterally flex the neck and head toward the affected shoulder. Then the examiner directs the patient to bring the chin as close as possible to the shoulder. The test may be repeated passively if there is no response when the patient does the action actively. The test is positive when the action causes radicular pain on the side of the flexion and rotation. A positive test reveals cervical nerve root compression in that the action narrows the diameters of the intervertebral foramina as much as anatomically possible. The Shoulder Depression Test . This test is done with the patient supine. The examiner standing at the head of the patient, flexes the neck to the side opposite to the shoulder being tested while pushing the shoulder caudad. Then, while maintaining the depression of the shoulder, the head is rotated, again to the side opposite to the shoulder being tested. If radicular pain is either produced or aggravated the first action and then confirmed by the second, the test is considered positive. A positive test indicates adhesions of the dural sleeves, the spinal roots, or the adjacent structures of the joint capsule on the side of the shoulder being depressed. Soto-Hall Test With the patient supine and the examiner exerting pressure on the sternum to prevent either lumbar or thoracic flexion, the examiner places the other hand under the patient’s occiput and flexes the head and neck slowly and forcibly upon the sternum. This causes more and more of a pull on the posterior spinous ligaments, starting at the Ligamentum Nuchae, moving downward until it reaches the spinous process of the involved vertebra. There the pull acts as a lever compressing the vertebral body, thus causing localized pain. This test is mainly used to diagnose and localize vertebral bony disease and injuries, particularly of the compression type. This patient’s pain was localized at C3/4. Spurling’s Test The examiner stands behind the seated patient and has the patient turn his or her head toward the involved side in maximal axial rotation and then maximal lateral flexion is added. The examiner then delivers a vertical blow to the uppermost portion of the cranium. Any significant increase of neck, shoulder or arm pain from the blow would be a positive test, indicating a stimulation of existing nerve root irritation or other problems related to disc disease and cervical spondylosis. Valsalva Maneuver This test is done on patients with cervical problems and is done with the patient seated. The examiner directs the patient to hold the breath and bear down, as if moving the bowels. This action increases intrathoracic pressure and if it results in an increase in cervical pain and radicular neuralgia the test is considered positive, indicating intervertebral nerve root compression from a disc occlusion. Thoracic Lesion Tests:TOP OF PAGEThe Chest Expansion Test With the patient standing or sitting erect, the examiner takes a chest measurement with the tape measure over the lowest part of the fourth intercostal space with the patient maximally exhaling. The patient then maximally inhales and another measurement is taken. Normal expansion for an adult male is at least two inches, and one and one-half inches for an adult female. Less than these amounts would be a positive test, indicating thoracic fixation. This is considered an important sign in any ankylosing condition such as Marie-Strumpell Disease. Forestiers Bowstring Sign In this test, the patient performs lateral bending while in a standing position. If there is ipsilateral tightening and contracture of the paraspinal muscles instead of the contralateral side tightening, the sign is present, indicating Ankylosing Spondylitis (Marie-Strumpell’s Disease). The Lewin Supine Test The supine patient with the arms held straight out above the thighs and the legs together and held down by the examiner is asked to sit up. If the patient cannot perform this action, the test is considered positive, indicating an ankylosing dorsolumbar spinal lesion. Schepplemann’s Sign The patient is asked to side bend with their arms over their head. Pain elicited on the concave side suggests intercostal neuritis. Pin on the convex side suggests generalized musculoligamentous strain/sprain Spinal Percussion The patient is seated while the doctor percusses the spinous process’ and paraspinal tissues. Pain during percussion of the spinous process suggests fracture or severe sprain. Pain during percussion of the paravertebral soft tissues suggests muscular strain or sensitive myofascial trigger points.Sternal Compression Test The patient is supine and the examiner exerts downward pressure on the sternum. A positive finding of lateral rib pain suggest possible rib fracture. Lumbar Lesion Tests:TOP OF PAGE Adam’s Sign This sign is present when acute bilateral low back pain results when flexion is performed from the standing Adam’s position, with flexion being the most painful position when compared to extension, lateral bending and rotation. Rotation is the freest and least painful of the spinal motions performed by the patient. This sign indicates an intervertebral disc posterior or posterolateral rupture, as forward flexion is the motion that most antagonizes this type of lesion, whereas rotation causes the least amount of stress in this type of pathology. Demianoffs Sign This sign is useful in differentiating sacrolumbalis muscle pain from lumbar pain of any other origin. In this test, the examiner performs straight leg raising on the supine patient. The sign is present when pain prevents the examiner from raising the leg more than fifteen degrees, indicating the pain is due to the stretching of the sacrolumbalis (Iliocostalis Lumborum Muscle). The Double Leg Raise Test This test is performed with the patient supine. The examiner straight leg raises each leg separately, noting the angle where pain in produced. Then both legs are raised together, again noting the angle where pain is produced. If the angle where pain occurs when both legs are lifted together is less than either leg when lifted separately, then this test is considered positive indicating lumbosacral joint involvement. Duchenne’s Sign In this test, the supine patient is asked to plantar flex the foot while the examiner pushes up (dorsally) the head of the first metatarsal with his or her thumb. The sign is present when the medial border of the foot dorsiflexes and the lateral border plantar flexes. Also, the head of the first metatarsal gives no resistance to the examiner’s thumb. A positive sign indicates paralysis of the Peroneus Longus from a lesion of the Superficial Peroneal Nerve or a lesion at or above the L4, L5 and S1 Nerve Roots. Goldthwait’s Sign This test is designed to differentiate between sacroiliac and lumbosacral involvement. With the patient supine, the examiner palpates the lumbosacral joint while slowly straight leg raising the limb on the affected side. The test is then repeated on the unaffected side. When pain is brought on before the lumbosacral joint is opened and it’s possible to raise the leg on the unaffected side to a greater level than the limb on the affected side without pain, then a lesion of the sacroiliac joint or ligaments is presumed. When no pain is experienced until the lumbosacral movement occurs and pain is felt when either leg is raised to approximately the same height then a lumbosacral lesion is more likely. The Lumbosacral Stress Test This test is used to localize posterior joint involvement in the lower lumbar motor units. The patient is in the prone position. Both legs are flexed at the knee and approximated to the buttock. A positive finding is pain at the lumbosacral junction without radiation to the lower extremities. This test demonstrates generalized musculoligamentous involvement of the lumbar spine and suggests strain/sprain The Low Back Hyperextension Test This test helps to localize low back lesions. The patient lies prone with the arms at the sides and legs straight and together. The examiner holds the legs down and has the patient lift the head, neck, and shoulders as far back as possible. Then the examiner has the patient point to the center of the pain resulting from this action. This patient pointed to L4/5. The Lasegue Differential Sign . This test is normally done on patients with Sciatica. If pain results from straight leg raising, but flexing the thigh on the pelvis with the knee flexed produces no sciatic pain, the sign is considered present, tending to rule out hip joint disease. The Lewin Punch Test In this test, if punching the left or right buttock of the standing patient produces a referred pain in the back, it is a positive test, indicating a spinal lesion, usually a protruded disc. The punched buttock that produces the pain is the side of the lesion. Punching the buttock on the side opposite the lesion, does not elicit pain. Lindner’s Sign This test is done with the patient supine. Standing behind the patient, the examiner enforces head, neck and dorsolumbar flexion, placing the patient’s trunk into a large “C-shaped” curve. The sign is present when this action aggravates or reduplicates the radicular pain of the patient’s main complaint, which is indicative of low back nerve root compression. Nachlas’ Test This test is performed with the patient in a prone position. Each foot is passively raised from the table, maximally flexing the knee. The examiner also exerts downward pressure over the pelvis to prevent buckling at the hips. The test is considered positive when the patient experiences pain in the sacroiliac region or the lumbosacral region, and at times, along the nerves that run in front of these joints, indicating a lesion of those joints. Smith-Peterson Test The examiner palpates the low back of the supine patient, while straight leg raising each leg. When there is acute inflammation, motion is more restricted toward the affected side. The opposite is true when the sacroiliac is involved. However, when straight leg raising, if pain begins after lumbosacral movement occurs, then a sacroiliac or lumbosacral lesion may be present. If the lesion is sacroiliac, the leg on the opposite side can be brought higher without pain If the lesion is lumbosacral, the pain comes on when both legs are at the same height. Sacroiliac Lesion Tests:TOP OF PAGE The Anterior Innominate Test This test is done on patients with lower trunk pain. The standing patient places the leg opposite the painful side two to three feet in front of the other foot. The patient then bends over the forward extremity putting all the weight on the front leg until the back foot raises off the floor. If this action causes or further aggravates the patient’s lower trunk pain, the test is considered positive, indicating a forward derangement of the ilia (anterior innominate) in relation to the sacrum. Erichsen’s Sign This test is done with the patient prone. The examiner, with the hands over the dorsum of the ilia, bilaterally thrusts toward the midline. If this produces pain over the sacroiliac area, the test is positive indicating sacroiliac joint disease as opposed to hip joint disease. Gaenslen’s Test On this test, the examiner has the patient lie supine with the affected side lying close to the edge of the table. The hip and knee on the unaffected side are flexed, while the patient clasps the flexed knee to his chest. The examiner then applies pressure against the clasped knee and the knee of the extended hip. If this action results in an exacerbation of pain from the pelvis, then the test is positive, indicating a sacroiliac joint lesion. Lewin-Gaenslen’s Test In this test, the patient lies on one side and pulls the knee of that same side up to the chest, while extending the other thigh. The examiner applies additional pressure from behind, forcing extension of the other thigh. Exacerbation of pain from the pelvis is considered a positive test, indicating a Sacroiliac joint lesion. Gillis’ Test On this test the examiner places the base of the palm of one hand over the prone patient’s sacroiliac joint on the unaffected side, thus fixing the sacrum with the fingertips fanning over the affected sacroiliac joint. With the other hand, the examiner lifts the thigh of the affected side putting the hip joint into extension. If this action exacerbates the pain of the main complaint over the sacroiliac joint, the test is considered positive, indicating Sacroiliac joint disease. Goldthwait’s Sign This test is designed to differentiate between sacroiliac and lumbosacral involvement. With the patient supine, the examiner palpates the lumbosacral joint while slowly straight leg raising the limb on the affected side. The test is then repeated on the unaffected side. When pain is brought on before the lumbosacral joint is opened and it’s possible to raise the leg on the unaffected side to a greater level than the limb on the affected side without pain then a lesion of the sacroiliac joint or ligaments is presumed. When no pain is experienced until the lumbosacral movement occurs and pain is felt when either leg is raised to approximately the same height, then a lumbosacral lesion is more likely. Hibb’s Test This test is performed with the patient in a prone position. The examiner, while stabilizing the pelvis on the side nearest to him, flexes the opposite knee to a right angle. From this position, the examiner slowly laterally pushes the leg causing strong internal rotation of the femoral head. The test is done bilaterally. Pelvic pain reveals a positive test, indicative of a sacroiliac lesion. Iliac Compression Test Used to rule out a sacroiliac lesion. Laguerre’s Sign This test is done with the patient supine while the thigh and knee are flexed to right angles. Then the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the hip joint capsule. The sign is present when this action produces pain, tending to rule out a lumbosacral lesion, but indicating a hip joint lesion, iliopsoas muscle spasm or a sacroiliac lesion.Nachlas’ Test This test is performed with the patient in a prone position. Each foot is passively raised from the table, maximally flexing the knee. The examiner also exerts downward pressure over the pelvis to prevent buckling at the hips. The test is considered positive when the patient experiences pain in the sacroiliac region or the lumbosacral region, and at times, along the nerves that run in front of these joints, indicating a lesion of those joints. The Sacroiliac Resisted Abduction Test This test is done with the patient lying on the side with the upper leg straight out and slightly abducted while the lower leg is flexed at the hip and knee for stability. With the patient resisting, the examiner applies downward pressure on the upper limb. The test is then repeated on the opposite side. If this action causes pelvic pain around the posterior superior iliac spine, the test is considered positive, indicating a Sacroiliac lesion, and more specifically, a sacroiliac sprain or subluxation. The Sacroiliac Stretch Test . This test is done with the patient supine. The examiner, with crossed arms, places his or her hands on the anterior superior spine of each ilium and applies pressure downward and laterally. The test is considered positive only if the patient can identify deep seated unilateral gluteal or posterior crural pain, as opposed to pain from table pressure on the skin over the sacrum, or from the examiner’s hands or from the lumbosacral area from the pelvis being rocked. A positive test would indicate an anterior sacroiliac ligament strain. Smith-Peterson Test The examiner palpates the low back of the supine patient, while straight leg raising each leg. When there is acute inflammation, motion is more restricted toward the affected side. The opposite is true when the sacroiliac is involved. However, when straight leg raising, if pain begins after lumbosacral movement occurs, then a sacroiliac or lumbosacral lesion may be present. If the lesion is sacroiliac, the leg on the opposite side can be brought higher without pain. If the lesion is lumbosacral, the pain comes on when both legs are at the same height. Yeoman’s Test This test is done with the patient in a prone position. The examiner exerts downward pressure over the suspected sacroiliac joint, while maximally flexing the ipsilateral knee. Then the thigh is hyperextended while holding down the pelvis. The test is positive when deep pain in both sacroiliac joints is causes from the above action, indicating a strain of the anterior sacroiliac ligaments. Sciatic Nerve Lesion Tests:TOP OF PAGE Bonnet’s Sign is used to rule out radiculopathy of the sciatic nerve. The test is similar to a Straight Leg Raise with the leg and though rotated internally Bragard’s Sign This test is done with the patient supine with both legs straight. The examiner straight leg raises the leg on the affected side until the point the patient feels pain. At this position, the examiner firmly dorsiflexes the foot. If there is an increase in radicular pain from the above, the test is considered positive, indicating peripheral or nerve root irritation of the sciatic nerve. Deyerle’s Sciatic Tension Test . This test is performed with the patient seated. The examiner extends the affected leg at the knee to the point of the pain being reproduced. Then the knee is slightly flexed with firm pressure being applied in the popliteal fossa. If radiculitis symptoms are increased, the test is considered positive, indicating a sciatic nerve lesion, in that the test shows irritation of the sciatic nerve above the knee from stretching the nerve over an obstruction. The Lasegue (Straight Leg Raise) Test This test is done with the patient supine and with the knee in extension. The examiner, actively flexes each thigh slowly while holding the other hand on the knee to prevent its flexion. The leg is lifted 90 degrees or until pain prevents further motion. The final angle of flexion at which pain occurs, as well as the location and intensity of the pain are noted by the examiner. This test is considered positive when the straight leg cannot be raised to 90 degrees without pain. Sicard’s Sign With the patient supine and legs fully extended, the examiner lifts the leg to a point that is just short of producing pain. Then the great toe is dorsiflexed. The sign is present when this action results in sciatic pain, indicating sciatic radiculopathy.Turyn’s Sign This test is performed with the patient supine with both legs straight out. If dorsiflexion of the great toe brings on pain in the gluteal region, then the sign is present, indicating sciatic radiculopathy. Intervertebral Disc Syndromes:TOP OF PAGE Amoss’ Sign This test is usually performed on patients with dorsolumbar or lumbosacral complaints. The patient is made to lie on his or her side and then is told to rise from the table. When this action of arising from a recumbent position causes significant localized thoracic or lumbosacral pain, the test is considered positive. A positive test indicates either Ankylosing Spondylitis, Severe Sprain or Intervertebral disc Syndrome. Bechterew’s Test (seated straight-leg raising) is used to rule out a lumbosacral intervertebral disc protrusion. The Bowstring Sign This test is done with the patient supine. The examiner performs straight leg raising until the patient experiences some discomfort. At this level the examiner flexes the knee slightly and rests the foot on his or her shoulder until any pain subsides. The examiner then applies pressure to the hamstrings. If this doesn’t produce pain, the examiner moves the thumbs over the popliteal fossa and applies pressure over the popliteal. If pain is reproduced in the leg or in the back, this sign is considered present, indicating nerve root compression or a ruptured intervertebral disc. Cox Sign. This test is performed with the patient supine. The examiner performs straight leg raising, and if the patient’s pelvis rises from the table instead of the hip being passively flexed, then the sign is present. The sign indicates a disc Prolapse into the Intervertebral Foramen. Dejerine’s Sign is used to rule out a mechanical obstruction from a herniated disc, tumor or bony closure. Fajersztajn’s “Well Leg Raising” Test This test is used when unilateral sciatica is present. The examiner passively straight leg raises the unaffected limb to the point of causing or increasing radiculitis in the opposite side. When none is produced, then strong dorsiflexion of the foot is added. The test is positive when either of these two actions produce radicular pain on the opposite side to the leg being lifted. A positive test tends to confirm the existence of a ruptured disc lesion as it produced sciatica at the nerve root level. Kemp’s Test This test can be done with the patient standing or sitting. While stabilizing the pelvis, the patient’s shoulder if firmly forced obliquely backward, downward and medial. The idea is to put the lower spine on the opposite side to the one being tested, into a combined position of rotation, lateral bending, and extension. The test is considered positive when low back pain radiates into the lower extremity, indicating facet syndrome, fracture or disc involvement. The Lasegue Rebound Test This test is done with the patient supine with the arms at the side. The examiner performs straight leg raising on the side of the main complaint until reaching muscle resistance or pain as indicated by the patient. The leg is then dropped into a pillow or the examiner’s hand, without warning. If this action aggravates backache and sciatic pain and low back spasm, the test is considered positive, which is particularly diagnostic of Psoas spasm or irritation, and generally indicative of an intervertebral disc lesion above the lumbosacral level. Lewin Snuff Test . In this test, the patient is given a pinch of mild pepper, snuff, etc. to sniff up the nostril in order to cause sneezing. If the resultant sneezing causes a localized spinal and radicular pain, the test is considered positive. A positive test indicates an intervertebral disc Rupture. The Sitting Root Test In this test, the patient is seated in a chair with the neck flexed. The examiner extends the knee on the affected side up to ninety degrees. Low back pain and radiation of the pain indicate the test is positive. This test places abnormal tension on the Sciatic Nerve and patients with true Sciatica will tend to arch backwards and complain of radicular pain. A malingerer will not complain of any symptoms. Milgram’s Test . This test is performed with the patient supine while both limbs are held straight out with the heels two to three inches from the table for at least 30 seconds. The test increases subarachnoid pressure and is positive when the patient is unable to hold the position for 30 seconds without pain, indicating pathology within or outside the spinal cord sheath, such as a herniated disc. Naffziger’s Test On this test, the examiner stands behind the seated patient and compresses both internal jugular veins with the index and middle fingers for a period of up to forty-five seconds. If this results in radiating sciatic pain, the test is considered positive, indicating nerve root compression by an extruded disc or other mass. Nervous System Lesion Tests:TOP OF PAGE The Ciliopupillary Reflex The Ciliopupillary Reflex This test has the patient seated erect, looking straight ahead. The examiner carefully observes the size and shape of the patient’s pupils while passively and maximally rotating the patient’s head and neck to one side and then the other. This reflex is observed when either pupil becomes larger or smaller after the head and neck have been rotated, indicating a positive test. A positive test is indicative of an Autonomic Nervous System lesion. This reflex is considered to be especially important on a post-traumatic basis, such as when the patient suffers a “whiplash” type injury to the cervical spine. Huntington’s Sign This test is performed with the patient supine with the legs hanging over the edge of the table at the knees. The examiner has the patient cough hard at least three times. If this action causes flexion of the thigh and extension of the knee on the weak side, the sign is considered present, indicating the weakness may be due to an Upper Motor Neuron Lesion. Morquio’s Sign The supine patient’s legs are straight out with the examiner at the head of the patient attempting to raise the patient to a sitting position, with the patient vigorously resisting. If when the patient’s knees and hips are placed into passive flexion the trunk can be lifted to a sitting position with little opposition, then this sign is considered present. The sign is indicative of Epidemic Poliomyelitis. O’Connell’s Test In this test, the patient’s unaffected leg is raised straight, with the angle of flexion noted along with the location of pain, if any. Then the affected leg is tested in the same way. Then, both legs are simultaneously flexed just short of the point of pain. The good leg is then lowered and if this last action causes an exacerbation of pain on the affected side, the test is considered positive, indicating lumbar peripheral neuropathy. Specifically, a positive test is evidence of neuritis proximal to the distal extent of the radiculopathy. Thomas’ Test On this test, the examiner maximally flexes the supine patient’s hip and knee of the side opposite to the side being tested, bringing the knee to the patient’s chest. The examiner then has the patient clasp the knee in order to maintain this posture. If this action causes the hip and knee of the opposite limb to elevate off the table, the test is considered positive. Normally, the opposite limb should have enough hip flexor stretch to allow the thigh to continue to lie flat on the table during this action. Thus a positive test indicates flexor tightness or flexion deformity of the hip. Miscellaneous Soft Tissue Lesion Tests:TOP OF PAGE The Sign of the Buttock The Sign of the Buttock On this test, the examiner performs a straight leg raise test on the supine patient. If this action along with passive hip flexion with the knee extended are both limited and painful, with the pain originating from the buttock as opposed to the hip, lumbosacral spine, etc., then this sign is considered present. When fever is also present it indicates inflammation of the upper femur (osteomyelitis), the sacroiliac joint (septic arthritis), ischio-rectal abscess or septic bursitis. If there is no accompanying fever, then neoplasm of the upper femur or iliac bone would be suspected. Dejerine’s Signs Also know as Dejerine’s Triad involves coughing sneezing and straining during defication which reproduces and aggravates radicular symptoms . This sign is present in space occupying lesions which can be caused from herniated discs, spinal cord tumor, fracture, etc. The course of the referred pain helps to localize the suspected lesion. Hueter’s Fracture Sign This test can be used to differentiate types of lesions, such as semisolid lesions as distinguished from a more dense lesion such as a hard tumor, etc. In this test, the examiner marks the main point of irritation and two more points on either side of the central point. These marks are duplicated on the non-affected side in order to establish what normal sounds like. Using either a 512 cycle tuning fork or a percussion hammer on the bone on the opposite side of the lesion, the examiner listens to see how vibration is transmitted across the lesion site. The sign is present if the sound is not transmitted normally over the lesion site. If the lesion is semisolid, the sounds will be less distinct, duller and less intense than the normal side. If the lesion is more dense, the sounds will be sharper, more distinct and intense than the normal side. The Manual Percussion Test . On this test, the patient is prone with the arms hanging over the sides of the table with a firm pillow propping up the area to be examined. The examiner manually percusses each spinous process in the area of the main complaint with up to 15 pounds of downward pressure. The test is positive when this action duplicates and aggravates the pain of the main complaint. A positive test indicates a vertebral sprain/strain. Mennell’s Test This is a two stage test, with the second stage dependent upon the first. The first stage has the examiner’s thumbs over the prone patient’s posterior superior iliac spines. The thumbs are slid outward and inward as far as the superficial tissue laxity will allow. If the inward or outward pressure elicits tenderness and/or a reduplication of the pain of the main complaint, then the test is considered positive. Outward tenderness indicates sensitive deposits (myofascitis) of the gluteal aspect of the posterosuperior spine. If the pain and/or tenderness is elicited at the inward pressure, then the second stage is performed on the side or sides of the tenderness. In this second stage, the examiner first pulls the pelvis backwards and then pressures the pelvis forward. When the tenderness increases with the backward pressure but decreases with the forward pressure, then the significance of the inward tenderness is substantiated, indicating superior sacroiliac ligament strain due mostly to sprain or subluxation. Murphy’s Punch Test In this test, the patient can either be sitting upright or standing. The examiner, using the edge of the hand or the thumb, gives short jabbing blows under the twelfth rib posteriorly on either side. If this results in lancinating pain which either shoots straight through anteriorly or goes around the chest wall, the test is considered positive, indicating deep seated tenderness and muscular rigidity, as in kidney inflammation. The Percussion Test This test has the patient seated and bent over facing the floor. The examiner, standing behind the patient, strokes the spinous processes with a reflex hammer within and outside the main area of complaint, first moving superiorly, then moving inferiorly. This is then repeated on the paraspinal musculature in the same manner. The test is considered positive when the percussion reproduces or aggravates the pain of the main complaint. If the pain occurs on percussing the spinous process, it is indicative of joint lesion, such as sprain, subluxation, dislocation, etc. If the pain occurs on percussing the spinal musculature then it indicates a soft tissue lesion, such as a strain, rupture, etc. Thompson’s Test This test has the prone patient’s feet hanging over the edge of the examining table. The examiner squeezes the calf muscles on the affected side just below the widest part of the posterior portion of the leg. The test is positive when this action does not cause a reflex plantar flexion of the foot, indicating a complete rupture of the Achilles Tendon. Upper Extremity Tests:TOP OF PAGE Codman’s Sign This test is performed on patients with shoulder complaints. The examiner passively abducts the arm on the side of the complaint. The sign is considered present when the abduction can be done without pain and a sudden release of the patient’s arm (with it above the horizontal, which causes the deltoid to suddenly contract) causes shoulder pain and a hunching of the shoulder due to the absence of rotator cuff function. The sign is indicative of a rotator cuff tear (Rupture of the Supraspinatus Tendon) Cozen’s Test The examiner has the patient clench the fist tightly while dorsiflexing it. The patient maintains that position while the examiner then grasps the lower forearm and applies pressure counter to the dorsiflexion posture of the patient. If this action causes acute lancinating pain in the lateral epicondyle region, the test is considered positive, indicating Tennis Elbow (Epicondylitis; Radiohumeral Bursitis) Dawbarn’s Sign This test has the patient standing with the arms hanging loosely at the side. The examiner deeply palpates the patient’s shoulder eliciting a localized tender area. The examiner, while leaving the finger on the painful spot, passively abducts the patient’s arm. This sign is present when the painful spot disappears on abduction, indicating Subacromial Bursitis. Dugas’ Test is used to rule out a shoulder dislocation. Hamilton’s Ruler Test This test is considered positive if a straight edge, such as a ruler or a yardstick, can rest on the acromial tip and the lateral epicodyle of the elbow at the same time. A positive test is indicative of a shoulder dislocation. Impingement Sign The patient’s arm is moved through flexion while in a slightly abducted position. This results in a jamming of the greater tuberosity against the acromial surface. Pain at the shoulder is a positive sign suggestive of overuse injury of the supraspinatus and/or biceps muscle tendon. Maisonneuve’s Sign This sign is present when there is marked hyperextensibility (Dorsiflexion) of the hand, which is one of the symptoms of Colles’ Fracture. Mill’s Maneuver The patient fully extends the elbow while fully flexing the wrist and fingers. Then the patient maximally pronates the forearm. If this action causes sharp tenderness and pain at the lateral elbow joint, then the test is considered positive, indicating Radiohumeral Epicondylitis (Tennis Elbow). This test is considered to be the classic maneuver for Tennis Elbow, because the action will only aggravate a true “Tennis Elbow”, and no other lesion. The Shoulder Compression Test The patient sits upright and the examiner palpates the distal apex of the coracoid process and marks it. The examiner then applies downward pressure over the marked area. When this action produces symptoms similar to neurovascular compression of the Subclavian Artery and Brachial Plexus, the test is considered positive indicating Coracoid Pressure Syndrome identical to a hyperabduction type of Thoracic Outlet Syndrome. The Supraspinatus Press Test On this test, the seated patient hangs the upper extremities limply at the sides. The examiner, using the thumb, presses toward the midline at a midclavicular point above the scapular spine. If this causes or exacerbates shoulder pain, then the test is considered positive, which is indicative of a Rotator cuff tear of the Supraspinatus Tendon. Yergason’s Test This test has the examiner facing the seated patient and slightly lateral to the upper extremity being tested. The patient, with the palm facing upward, makes a fist and bends the elbow to about 90 degrees. The examiner palpates over the bicipital groove while clasping the patient’s fist. The examiner then internally and externally rotates the patient’s arm while also keeping the patient from further flexing the elbow. If this action causes a painful palpable and/or audible click or snap, which is the bicipital tendon slipping in and out of the bicipital groove, then this test is considered positive, which indicates a loss of stability of the Biceps’ Tendon. Hip Lesion Tests:TOP OF PAGE Ely’s Heel to Buttock Test This test is a two stage test done with the patient in a prone position. First the knee is flexed to the opposite buttock. Then the thigh is hyperextended. If this action cannot be performed normally, then the test is positive, indicating one of the following: a hip lesion, irritation of the Iliopsoas muscle or its sheath, inflammation of the lumbar nerve roots, or the presence of lumbar nerve root adhesions. The Hip Abduction Stress Test On this test, the patient lies on the non-affected side and actively abducts the affected limb at the hip. The patient holds the limb in abduction while the examiner exerts downward pressure on it. If this action brings on pelvic pain, then the test is considered positive, indicating a sacroiliac lesion. Laguerre’s Sign This test is done with the patient supine while the thigh and knee are flexed to right angles. Then the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the hip joint capsule. The sign is present when this action produces pain, tending to rule out a lumbosacral lesion, but indicating a hip joint lesion, iliopsoas muscle spasm or a sacroiliac lesion.Patrick’s Test Performed with the patient supine, the examiner places the external malleolus over the patella of the opposite limb. Then downward pressure is applied to the thigh. When pain results from this action, particularly in the hip flexor area, the test is positive. A positive test suggests hip joint disease, because this action antagonizes hip flexor spasm brought on by an inflammatory lesion. This test is also known as the FABER or FABERE Sign from the acronym of the maneuver: Flexion, Abduction, External Rotation and Extension. Thomas’ Test On this test, the examiner maximally flexes the supine patient’s hip and knee of the side opposite to the side being tested, bringing the knee to the patient’s chest. The examiner then has the patient clasp the knee in order to maintain this posture. If this action causes the hip and knee of the opposite limb to elevate off the table, the test is considered positive. Normally, the opposite limb should have enough hip flexor stretch to allow the thigh to continue to lie flat on the table during this action. Thus a positive test indicates flexor tightness or flexion deformity of the hip. Trendelenburg’s Test In this test, the patient stands on one foot, using a wall or chair for support. The patient then lifts the opposite knee above waist level. The test is done bilaterally. This action will normally elevate the gluteal fold and pelvis of the side being lifted above that of the standing leg side. When the gluteal fold and pelvis on the side being lifted are lowered, the test is considered positive, indicating a gluteal (abductor) insufficiency on the standing leg side. Hamstring Tests:TOP OF PAGE The Lewin Standing Test This test has the patient standing on a short stool or platform with the examiner stabilizing the patient’s pelvis from behind with one hand. The other hand sharply pulls the patient’s knee (on the same side) into extension. This action is repeated on the opposite side. Then the examiner braces his or her shoulder against the patient’s sacrum and pulls both knees into extension. If any of these actions results in pain followed by either or both knees snapping back into flexion, then this test is considered positive indicating unilateral or bilateral Hamstring spasm. Neri’s Bowing Sign Is used to rule out unilateral tight and spastic hamstrings, which would be indicative of sacroiliac, lumbosacral or lumbar lesions. This sign is fairly constant in lumbar radiculopathy and may also be present in sciatic peripheral neuropathy. The Tripod Sign is used to rule out tightness of the hamstring muscles, which exists in almost any spinal irritation from the midthoracic area to the sciatic notch. Lower Extremity Tests:TOP OF PAGE The Abduction Stress Test On this test, the supine patient’s knees are in complete extension. The examiner places one palm against the lateral aspect of the knee at the joint line of the side being tested and with the other hand the examiner grips the ankle pulling it laterally, thus opening the medial side of the joint. If this action causes no pain, then the examiner repeats it with the knee in approximately thirty degrees of flexion, which puts the knee joint maximally vulnerable to a torsion stress. If either of these actions produces or exacerbates pain, below, above or at the joint line, then the test is considered positive, indicating a medial collateral ligament injury. The Adduction Stress Test This test is done with the patient supine and the knees in complete extension. The examiner places on palm against the medial aspect of the patient’s knee (opposite to the one being tested) at the joint line. With the other hand the examiner grips the ankle, pulling it medialward, thus opening the lateral side of the joint. If this action causes no pain, then the examiner repeats it with the knee in approximately thirty degrees of flexion, which puts the knee joint maximally vulnerable to a torsion stress. If either of these actions produces or exacerbates pain, below, above or at the joint line, then the test is considered positive, indicating a lateral collateral ligament injury. The Apley Test This test involves four steps. If any or all of them elicit knee pain or clicking, the test is considered positive. In Step 1, the patient is in a prone position with the ankles hanging over the end of the table. The examiner grasps the foot, strongly rotating the leg internally flexing the knee past ninety degrees. Step 2 is the same as Step 1, except the leg is rotated externally. On Step 3, the examiner anchors the patient’s thigh to the table by placing his own knee in the patient’s popliteal space cushioned by a pillow or towel while strongly lifting up on the foot, followed by rapidly rotating the leg internally and externally. Step 4 is the same as Step 3 except the examiner pushes downward instead of lifting. A positive test is indicative of a meniscus tear The Childress Duck Waddle Test On this test, the standing patient first attempts to fully squat with the legs somewhat apart and in maximal internal rotation. The action is then repeated with the legs in maximal external rotation. If either of these actions results in pain or if the patient is unable to fully flex the knee and/or if there is a clicking sound on either posterior side of the joint, then the test is considered positive, indicating a medial or lateral meniscus tear. Dreyer’s Sign On this test, the supine patient attempts to actively raise the affected leg with the knee fully extended. If the patient is able to perform this action only when the examiner applies forceful extension to the thigh using the flat of the hands which gives anchorage to the patient’s quadriceps, then the sign is considered present. The sign indicates a fracture of the patella. Ely’s Sign On this test, the prone patient’s knee is flexed toward the buttock on the same side. If the pelvis rises off the table and the thigh goes into abduction at the hip joint, both somewhat in unison with the knee flexion, then this test is considered positive, indicating a Rectus Femoris and/or lateral thigh fascia contracture. Hennequin’s Sign This sign is present when digital compression by the examiner below Poupart’s (inguinal) ligament, lateral to the major vessels, causes pain, tenderness and crepitation. If the sign is present, it indicates a fracture of the neck of the femur. The Anterior Foot Draw Sign This test is done with the patient seated on an examining table with the legs hanging over the table’s edge. The examiner places one hand around the anterior aspect of the lower tibia just above the ankle. The other hand grips the calcaneus. While pushing the tibia posteriorly, the calcaneus (and talus) is drawn anteriorly. This sign is present when the above action causes the talus to slide anteriorly from under cover of the ankle mortise, indicating anterior talofibular ligament instability, usually secondary to rupture. Hoffa’s Sign This test has the prone patient’s ankles hanging over the edge of the examiner’s table. By movement and palpation, the examiner checks the Achilles Tendon on the involved side to see if it’s less taut than the other side as well as checking for increased dorsiflexion in the relaxed position. If either of these is the case, then the sign is present, indicating an avulsion fracture of the calcaneus. A loose fragment may also be seen and/or felt behind either malleolus. The Metatarsal Test This test has the seated patient’s lower limbs straight out with the feet extending over the table. First, the examiner forcibly extends the outer four toes so that the ball of the foot is made prominent. Then the examiner percusses the protruding metatarsophalangeal joints of the outer four toes with a reflex hammer. When this action causes neuritic pain, the test is considered positive, indicating Anterior Metatarsalgia due to inflammation of the metatarsophalangeal joints. Strunsky’s Sign This test has the patient supine with one foot resting in the examiner’s hand. With the other hand the examiner grasps the patient’s toes and flexes them suddenly. Normally, this action produces no pain. When it causes lancinating pain, the sign is present, indicating inflammation of the anterior arch of the foot, mainly the Metatarsophalangeal Joints. Circulatory Disorder Tests:TOP OF PAGE Adson’s Maneuver . On this test, the patient is seated while the examiner palpates the radial pulse to determine its rate, force and amplitude. The examiner then has the patient rotate the head to the side being tested, followed by elevating the chin as high as painlessly possible, and finally taking a deep breath and holding it for about 10 seconds. The test is positive when this action stops or diminishes the radial pulse rate. If the above maneuver is negative the test should be repeated with the patient rotating the head opposite to the side being tested. A positive test indicates a subclavian artery compression commonly caused by a cervical rib thoracic outlet syndrome and/or scalenus anticus syndrome. Allen’s Test This test has the patient seated with the forearms resting on the thighs and the palms facing up. First the patient makes a fist on the side being examined, then the examiner digitally occludes either the radial or ulnar arteries right next to the wrist while the patient maintains the clenched fist. Next, with the examiner maintaining the occlusion, the patient opens the hand. Normally, the color returns to that hand in ten seconds or less. The test is considered positive if there is a delayed color return during digital compression, indicating a partial blockage, or if there is no color return until the examiner releases the wrist which indicates a complete blockage of the artery which is not being compressed. Buerger’s Test This test measures arterial blood supply to the lower limbs. The examiner straight leg raises the supine patient’s leg to about 45 degrees for no less than three minutes. The examiner then lowers the limb and has the patient sit up with both legs hanging over the examining table. The test is considered positive if the dorsum of the foot blanches and any prominent veins collapse when the leg is initially straight leg raised, or if after lowering the leg it takes one or two minutes for a ruddy cyanosis to spread over the affected part and for the veins to once again become prominent, either of which indicates a deficient blood supply. George’s Test Many doctors use this test before attempting any high velocity cervical manipulation. The supine patient extends the head and neck over the edge of the table. With eyes open the patient actively rotates the head and neck while maintaining the extended position. One or more of the following indicates a positive test: either blanching or cyanosis of the face, nystagmus, sweating, dizziness, nausea, headache or an increase of temperature. Until vascular disorders are ruled out by further examination, a positive test would indicate that cervical manipulation involving rotation and/or extension is contra-indicated. Homan’s Sign This test is done with the patient supine with the knee extended. When dorsiflexion of the ankle by the examiner causes a localized deep pain either in back of the calf or behind the knee, the sign is considered present, indicating Thrombophlebitis (thrombosis of the deep veins of the leg). The Moskowicz Test In this test, the patient’s extremity being tested is wrapped firmly with an elastic bandage, elevated and held there for 5 minutes. The extremity is then released and quickly unbandaged. Normally, the blood rapidly flows back into the area as the bandage is removed, seen by a hyperemic blush. The test is considered positive when the blush is either absent or slight and lags behind the unbandaged area, indicating an inadequacy of collateral circulation, as in an arteriovenous fistula. Wright’s Test This test is usually performed after the Allen’s Test in order to rule out other underlying pathology which would be indicated by the Allen’s Test. The seated patient has both arms hanging at the sides, with the examiner behind the patient. The examiner palpates the radial pulse during 180 degrees of active and then passive abduction of both arms, while noting at how many degrees of abduction the radial pulse on the affected side diminishes or disappears when compared to the opposite side. If this action diminishes or eliminates the radial pulse, the test is considered positive, indicating a neurovascular compression of the Axillary Artery as seen in the Hyperabduction Thoracic Outlet Syndrome. Tests for Malingering:TOP OF PAGE Burn’s Bench Test On this test, the patient kneels upright on the examining table or a padded bench that is about eighteen to twenty inches high. The examiner firmly grasps the patient’s ankle from behind and instructs the patient to bend over and touch the floor with the fingertips. Patient’s who normally cannot be expected to carry out this action are those extremely weak from injury or disease or those significantly diseased at the hip or knee. Those patients who may be able to perform the action are those with sciatic neuralgia, congenital anomalies, arthritis, a specific disease of the spine (such as tuberculosis), or a compression fracture of the spine. Any patient (other than those mentioned above who cannot be expected to carry out this action) either refuses to perform the action or claims they can only go part way, is presenting evidence of malingering or hysteria. Hoover’s Sign When the patient is alleging unilateral lower limb paralysis, the examiner places the hands under the heels of the supine patient. The patient is then asked to lift the paretic leg. If the leg is truly weak or paralyzed, the patient will involuntarily push downward with the non-affected leg, which would be felt as pressure on the examiner’s hand. The sign is present if no counterpressure can be felt by the examiner on the healthy side, which is evidence of malingering or hysteria. Lasegue’s Sitting Test is used for indicating low back radiculopathy, spasmophilia or lumbar disc herniation. This test has the patient sitting upright on the edge of an examining table or bench without a backrest. The examiner extends the patient’s legs below the knee one at a time, so each limb is parallel with the floor. If there is no radiculoneuropathy, the patient should experience no discomfort from this action. This is a modification of the Lasegue Straight Leg Raise. It has advantages when checking for malingering, because the test can be performed without the patient knowing what is being tested. This version can be used on those patients where simulation, falsifying or magnification of symptoms is suspected. Magnuson’s Test This test is performed when malingering or hysteria is suspected in the patient with low back complaints. The patient points to the site of the pain which in turn is marked by the examiner. The examiner then performs other actions away from the marked site of pain. The test is positive if there is any significant change of the pain site once the examiner resumes the examination of the low back. A positive test would indicate evidence of simulated pain, hysteria or malingering.